• Attention: performance on serial sevens, digit span tests
• Abstraction: performance on tests involving similarities, proverbs
• Insight - what do they know about their own disease
• Judgment
Ideas of Harming Self or Others
• Suicidal or homicidal thoughts:
• Presence of a plan
• Means to carry out the plan
• Opportunity to carry out the plan
Psychosocial Assessment includes:
A Previous hospitalizations
B. Educational background
C. Occupational background
D. Social patterns - family/friends
E. Sexual patterns
F. Interests & Abilities
G. Substance use & abuse
H. Coping abilities
I. Spiritual assessment
Components of a Nursing Diagnosis
Problem
Etiology related to
Supporting data as evidenced by
Outcomes (third step in nursing process after Diagnosis) have these three criteria:
Attainable
Measurable
Time estimate for attainment
Planning, the 4th step of the nursing process, identifies Interventions that are:
Safe
Compatible & appropriate
Realistic & Individualized
Evidence based
Spirituality has three dimensions: AAA. BBB and CCC. The AAA component includes beliefs, such as believing in the love of a spouse. The CCC component deals with daily behaviors and life choices, such as finding the time to pray or being happy with choices one makes in life, whether others support those choices or not. The BBB component deals with love, compassion, altruism, and forgiveness.
A) cognitive
B) experiential
C) behavioral
In psychiatric nursing, assessment of a "client" refers exclusively to
C. an individual, family, group, or community.
Standards of practice for psychiatric nursing indicate that the client can be an individual, a family, a group, or a community. Text page: 138
High levels of anxiety and maladaptive behavior are
D. in all areas in the health care setting.
Anxiety occurs whenever individuals are faced with unfamiliar circumstances or other threats to the self. The health care setting presents many possible threats to the self, such as illness, disability, surgery, and pain. Text page: 140
Which activity is not considered a purpose of initial psychiatric assessment?
B. Evaluate results of intervention
At an initial assessment, no interventions would have taken place; hence evaluation is not a purpose of the initial contact. Text pages: 140, 141
The nurse best ensures appropriate client care when choosing an intervention from a Nursing Interventions Classification that match the:
B. the defining data and nursing diagnosis
When choosing a nursing intervention from the Nursing Interventions Classification or other source, the nurse uses ones that fit the nursing diagnosis (e.g., risk for suicide) and interventions that match the defining data. Text pages: 147, 148
What three structural components comprise a nursing diagnosis?
A. Problem, etiology, supporting data
A beginning nurse writing outcome criteria might refer to the:
C. Nursing Outcomes Classification (NOC).
When planning care the nurse may eliminate which of the following as an essential principle? Which criterion is not essential for the nurse to observe when planning nursing interventions designed to meet a specific goal? The intervention will be
A. Interventions must be supported by the Nursing Outcomes Classification.
NOC does not distinguish between short- and long-term outcomes. However, the clinical chapters of the text distinguish among the outcomes to demonstrate that the achievement of some outcomes is possible in the short term, whereas others will require more time with the client. Text page: 149
Interviewer anxiety during an assessment interview is most likely to stem from
B. the client's perception of the interviewer's ability to help the client.
A. the client's perception of the interviewer's ability to help the client.
A factor that will interfere most with obtaining data in an initial assessment interview of an older adult is
C. client's physical and cognitive deficiencies.
A nurse is interviewing a new client who is angry and highly suspicious. When the nurse asks about a client's sexual orientation, the client becomes highly distressed and threatens to walk out of the interview. The nurse should say
A. "I can see that this topic makes you uncomfortable. We can defer discussion of it today."
A cardinal rule of interviewing is "Don't probe sensitive areas." Clients are allowed to take the lead. Text page: 140
A nurse is about to interview a client whose glasses and hearing aid were placed in safe keeping when she was admitted. Before beginning the interview, the nursing intervention that will best facilitate data collection is to
D. assist the client in putting on glasses and hearing aid.
A client whose hearing or sight is impaired may have difficulty providing information if these items have been removed from his or her possession. Assisting the client in wearing these assistive devices is the best initial intervention. Text page: 140
Author
TomWruble
ID
198906
Card Set
NUR210CH08
Description
The Nursing Process and Standards of Care for Psychiatric Mental Health Nursing
